Working together to improve health care quality, outcomes, and affordability in Washington State.
Behavioral Health Integration Report and Recommendations
March 2017
Table of Contents
Executive Summary............................................................................................................................1
Dr. Robert Bree Collaborative Background ..........................................................................................2
Defining Integrated Care ....................................................................................................................3
Stakeholder Actions and Quality Improvement Strategies .................................................................11
Patients and Family Members ................................................................................................................ 11
Primary Care Practices and Systems (including Primary Care and Behavioral Health Care Providers) .. 11
Health Plans ............................................................................................................................................ 12
Employers ............................................................................................................................................... 12
Washington State Health Care Authority ............................................................................................... 12
Problem Statement ..........................................................................................................................13
High Unmet Need ................................................................................................................................... 13
The Case for Integration ......................................................................................................................... 13
Background: Towards an Integrated System .....................................................................................15
Integrating Behavioral Health into Physical Health ................................................................................ 16
Screening, Brief Intervention, and Referral to Treatment ...................................................................... 19
Integrating Primary Care into Behavioral Health .................................................................................... 20
Deeper Dive: The Patient Perspective ...............................................................................................22
Primary Care Practice.............................................................................................................................. 22
Behavioral Health Clinic .......................................................................................................................... 22
Measurement ..................................................................................................................................23
Healthcare Effectiveness Data and Information Set ............................................................................... 23
National Quality Forum........................................................................................................................... 23
Washington State Common Measure Set on Health Care Quality and Cost .......................................... 24
Current State of Integration .............................................................................................................25
Integrated Funding in Washington State ................................................................................................ 25
Washington Screening, Brief Intervention, and Referral to Treatment ................................................. 26
Mental Health Integration Program ....................................................................................................... 27
Next Steps to Full Integration ...........................................................................................................28
Overcoming Barriers ............................................................................................................................... 28
Implementation Guides .......................................................................................................................... 29
Appendix A: Bree Collaborative Members ........................................................................................30
Appendix B: Behavioral Health Integration Workgroup Charter and Roster .......................................31
Appendix C: Crosswalk of Eight Elements with MeHAF ......................................................................33
References.......................................................................................................................................34
Executive Summary
The Robert Bree Collaborative was established in 2011 to provide a forum in which public and private
health care stakeholders can work together to improve quality, health outcomes, and cost-effectiveness
of care in Washington State. Mental illness and substance use disorders, together called behavioral
health, are common and often go untreated due to stigma, lack of screening, and lack of access to
appropriate care. Integrating behavioral health care into primary care, and primary care into behavioral
health care has been proposed as a solution, but integration has been variable and inconsistent. The
Bree Collaborative elected to address this topic and convened a workgroup to develop
recommendations from April 2016 to March 2017.
This Report and Recommendations is focused on integrating behavioral health care services into primary
care for those with behavioral health concerns and diagnoses for whom accessing services through
primary care would be appropriate. Our workgroup found it important to define integrated behavioral
health care in order to create a common vocabulary and focused on using available evidence and
existing models to develop eight common elements that outline a minimum standard of integrated care.
These eight elements are meant to bridge the different models used throughout Washington State and
across the country and include:
1.
2.
3.
4.
5.
6.
7.
8.
Integrated Care Team
Patient Access to Behavioral Health as a Routine Part of Care
Accessibility and Sharing of Patient Information
Practice Access to Psychiatric Services
Operational Systems and Workflows to Support Population-Based Care
Evidence-Based Treatments
Patient Involvement in Care
Data for Quality Improvement
Our goal is that these eight elements will allow providers and practices to know when they have
achieved integrated care, patients to know when they are receiving integrated care, and purchasers and
health plans to know when they are buying integrated care. The eight elements along with
specifications; a description from the perspective of the patient to keep the patient front and center in
care delivery; and a description of usual care, intermediate steps toward full integration, and a full
description of integrated care are discussed on page 6. The remainder of this Report is meant to support
these eight elements including detailing:
•
•
•
•
•
•
•
Recommendations specific to stakeholder groups to achieve integration including for patients,
primary care practices including primary care and behavioral health care providers, health plans,
employers, and the Washington State Health Care Authority,
The problem with high unmet behavioral health needs,
Integrated care including our workgroup definitions for integrated care,
The background of previous work to research and develop models of integrated care,
Additional description of integrated care from the patient’s perspective,
National and state-level measures and processes for measurement, and
The current state of financial and clinical integration.
Adopted by the Bree Collaborative, March 22, 2017.
Page 1 of 37
Dr. Robert Bree Collaborative Background
The Dr. Robert Bree Collaborative was established in 2011 by Washington State House Bill 1311 “…to
provide a mechanism through which public and private health care stakeholders can work together to
improve quality, health outcomes, and cost effectiveness of care in Washington State.” The Bree
Collaborative was modeled after the Washington State Advanced Imaging Management (AIM) project
and named in memory of Dr. Robert Bree, a pioneer in the imaging field and a key member of the AIM
project.
Members are appointed by the Washington State Governor and include public health care purchasers
for Washington State, private health care purchasers (employers and union trusts), health plans,
physicians and other health care providers, hospitals, and quality improvement organizations. The Bree
Collaborative is charged with identifying up to three health care services annually that have substantial
variation in practice patterns, high utilization trends in Washington State, or patient safety issues. For
each health care service, the Bree Collaborative identifies and recommends best-practice evidencebased approaches that build upon existing efforts and quality improvement activities aimed at
decreasing variation. In the bill, the legislature does not authorize agreements among competing health
care providers or health carriers as to the price or specific level of reimbursement for health care
services. Furthermore, it is not the intent of the legislature to mandate payment or coverage decisions
by private health care purchasers or carriers.
See Appendix A for a list of current Bree Collaborative members.
Recommendations are sent to the Washington State Health Care Authority for review and approval. The
Health Care Authority (HCA) oversees Washington State’s largest health care purchasers, Medicaid and
the Public Employees Benefits Board Program, as well as other programs. The HCA uses the
recommendations to guide state purchasing for these programs. The Bree Collaborative also strives to
develop recommendations to improve patient health, health care service quality, and the affordability of
health care for the private sector but does not have the authority to mandate implementation of
recommendations.
For more information about the Bree Collaborative, please visit: www.breecollaborative.org.
Mental illness and substance use disorders, together called behavioral health, are common, and often
go untreated due to stigma, lack of screening, and lack of access to appropriate care. Integrating
behavioral health care into primary care has been proposed as a solution, but integration has been
variable and inconsistent. The Bree Collaborative elected to address this topic and a workgroup
convened to develop recommendations from April 2016 to March 2017.
See Appendix B for the Behavioral Health Integration workgroup charter and a list of members.
Adopted by the Bree Collaborative, March 22, 2017.
Page 2 of 37
Defining Integrated Care
The Behavioral Health Integration workgroup and the Bree Collaborative recognize the value of bidirectional care (behavioral health care services integrated into primary care settings and primary care
services integrated into behavioral health care settings) to meet the wide variety of patient needs and to
provide care in the setting with which individuals are most comfortable. This workgroup and the
resulting Report and Recommendations focus on integrating behavioral health care services into primary
care for those with behavioral health concerns and diagnoses where accessing services through primary
care would be appropriate. This is a first step toward the goal of full bi-directional integration in which
the eight elements could be adapted to integrating primary care services in the behavioral health
setting.
Integration of behavioral and physical health care has been both facilitated and stymied by the
availability and use of different models. Research into shared characteristics of practices that have
successfully integrated the types of care suggest a need to move away from heuristics and toward
functions or approaches to integration that unify the various models. 1 Our Behavioral Health Integration
workgroup found it necessary to focus on functions or minimum standards that could be used across
settings for which practices would not have to hire additional on-site staff. It is clear that screening
without adequate treatment, referral to specialty care without close coordination or follow-up, and colocated behavioral health specialists without systematic tracking of outcomes or evidence-based
treatments do not work and are not recommended.
High-quality behavioral health care should draw from trauma-informed care appropriate to an individual
as defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) here. We use
the term “patient” throughout the document for clarity. The eight elements are meant to be applicable
to a wide variety of populations for whom primary care is the appropriate access point. Detailing
behavioral health interventions for specific populations are beyond the scope of this Report and
Recommendations such as for children and adolescents, pregnant and parenting women, older adults,
those with developmental or intellectual disabilities, and others. Practices should consider individual
and population-level attributes and appropriate care and tailor care accordingly within the context of
the framework of the eight elements. Care should be appropriate for an individual’s age, language,
religion, and cultural background. Our recommendations are designed for consenting adults. Parents of
pediatric patients and other family members should be involved in care decisions as appropriate.
Like the field in general, our workgroup first started by focused on integrating depression screening,
brief intervention, and referral to higher levels of treatment into primary care. We use a framework that
much like using a blood pressure cuff to track treatment outcomes in hypertension, practices monitor
behavioral health outcomes with a symptom rating scale to determine efficacy. We heavily drew from
AHRQ’s 2013 Lexicon for Behavioral Health and Primary Care Integration, the work of the AIMS Center in
Washington State, and the work of CCO Oregon. The AHRQ Lexicon “is a set of concepts and definitions
developed by expert consensus for what we mean by behavioral health and primary care integration—a
functional definition—what things look like in practice.” 2
Adopted by the Bree Collaborative, March 22, 2017.
Page 3 of 37
The AIMS Center uses five principles to define Collaborative Care: 3
•
•
•
•
•
•
Patient-centered team care: Collaboration between primary and behavioral health care
providers using a shared care plan
Population-based care: Defined patient group tracked in a registry with consultation from
specialists
Measurement-based treatment to target: Treatment plans based on patient goals and evidencebased tools (e.g., PHQ-9)
Evidence-based care: Use of therapeutic techniques shown to work in primary care (e.g.,
problem-solving treatment, cognitive behavioral therapy) and medication management
Accountable care: Reimbursement for quality and outcomes
Read more about these principles here
The Behavioral Health Integration workgroup does not endorse a specific tool to measure integration as
many have been and are successfully being used by practices. The Maine Health Access Foundation
(MeHAF) has developed a self-assessment for practices to assess level of integration. The assessment is
divided into (1) integrated services and patient and family-centeredness and (2) practice/organization
with 18 questions on a 10-point scale. The tool is available here. We crosswalk our eight elements with
the MeHAF questions in Appendix C as this tool has been used within Washington State.
The Oregon Legislature established the Patient-Centered Primary Care Home Program in 2009, working
with stakeholders to set standards for care within a medical home including behavioral health care. 4 In
2014, the Oregon Health Authority developed Patient-Centered Primary Care Home Program
Recognition Criteria. CCO Oregon, a non-profit member organization supporting delivery of quality care
at lower cost, convened the Integrated Behavioral Health Alliance of Oregon that met to develop
behavioral health quality incentive metrics and integration methods. The workgroup developed eight
minimum standards based on the AHRQ lexicon and definitions.
•
Read the recognition criteria here
•
Read these minimum standards here
Our goal is that these eight elements will allow providers and practices know when they have achieved
integrated care, patients know when they are receiving integrated care, and purchasers and health plans
know when they are buying integrated care. Our workgroup found it important to define integrated
behavioral health care in order to create a common vocabulary, see the definitions for Integrated Care
and Behavioral Health Provider on the following page. Behavioral and physical approaches must align for
integrated behavioral health, see Figure 1: Levels of Primary Care Integration on the following page. We
used this model, and the resources mentioned above, in the development of our eight key elements
detailed in Table 1: Specification for Integrated Care on page 6.
Adopted by the Bree Collaborative, March 22, 2017.
Page 4 of 37
Integrated Care
Team-based care provided to individuals of all ages, families, and their caregivers in a wholeperson oriented setting or settings by licensed primary care providers, behavioral health
clinicians, and other care team members working together to address one or more of the
following: mental illness, substance use disorders, health behaviors that contribute to chronic
illness, life stressors and crises, developmental risks/conditions, stress-related physical
symptoms, preventative care, and ineffective patterns of health care utilization.
Behavioral Health Provider
A licensed psychiatrist, a licensed psychologist, a licensed nurse practitioner or registered nurse
with a specialty in psychiatric mental health, a licensed independent clinical social worker, a
licensed mental health counselor, a licensed marriage and family therapist, a certified clinical
social work associate, an intern or resident who is working under a state-approved supervisory
contract in a clinical mental health field; or any other clinician whose authorized scope of
practice includes mental health intervention.
Figure 1: Levels of Primary Care Integration
Quality-Driven
Behavioral Health
Advanced Behavioral
Health Integration
Fundamental
Components of
Behavioral Health
Integration
Achievement
of Quadruple Aim
Quality-Driven
Primary Care
Access to Shared Care Plan
Close to Same Day Access
Registries/Tracking
Systematic Follow-Up
Risk Stratification/Protocols
Specialists Readily Accessible or Onsite
Preventative Medicine
EMR Technology
Treat “All Comers”
Evidence-Based
Expedited Access to Appointments
Validated Outcome Measurement/Assessment
Regular Screening and Intervention
Panel-Based Staffing/ Team-based care
Referral Access to Specialists
Adopted by the Bree Collaborative, March 22, 2017.
Advanced Primary Care
(PCMH Certification)
Fundamental Primary
Care Components
Page 5 of 37
Table 1: Specifications for Integrated Care
Table 1 is designed as a roadmap to implementation. Outlined below are (1) the eight elements, (2) specifications around the element, (3) a
description from the perspective of the patient to keep the patient front and center in care delivery, and (4) a description of usual care,
intermediate steps toward full integration, and a full description of integrated care.
Element
1
Integrated
Care Team
Specifications
Patient Perspective
Each member of the
integrated care team has
clearly defined roles for
both physical and
behavioral health
services. Team members,
including clinicians and
non-licensed staff,
understand their roles
and participate in typical
practice activities inperson or virtually such
as team meetings, daily
huddles, pre-visit
planning, and quality
improvement.
I can see how my
care team takes my
concerns into
consideration when
making treatment
decisions and can
talk to members of
my integrated care
team about any of
my concerns,
including feeling low
or depressed, or
concerns about my
drinking. The team
will be able to
answer my
questions and help
me get treatment if I
choose to.
Adopted by the Bree Collaborative, March 22, 2017.
Operational Details for Integrating Behavioral Health Care into Primary
Care
Usual Care: Behavioral health support is provided by the primary care
provider, who may not feel adequately supported or adequately trained in
managing all behavioral health conditions in his/her patient panel.
Steps Toward Integration: Behavioral health professionals are onsite or
available remotely but do not participate in clinic-level workflows and are
not part of the usual patient care. Behavioral health may closely coordinate
and follow up with the primary care provider on all patients that are referred
to them for treatment.
Integrated Care: Practices are committed to developing and maintaining a
culture of integration and teamwork including both engaging providers in
integrated approaches to care proven to help patients get better and
achieve their treatment goals and cross-training providers on behavioral
health and primary care. The integrated care team utilizes shared workflows
to systematically screen and treat common behavioral health conditions and
uses measurement-based behavioral health scales and tools to screen and
track patient progress toward treatment goals. Behavioral health
professionals participate in primary care workflows. Behavioral health
professionals may be practice-based, (i.e., located in the same physical space
as the integrated care team) or telemedicine-based (i.e., available to the
practice onsite on a regular but not daily basis and available by phone, pager
or videoconference) to assist primary care providers and patients during
practice hours when they are not onsite.
Page 6 of 37
2
3
Patient
Access to
Behavioral
Health as a
Routine Part
of Care
Accessibility
and Sharing
of Patient
Information
Access to behavioral
health and primary care
services are available on
the same day as much as
feasible. At a minimum, a
plan is developed on the
same day that includes
continuous patient
engagement in ways that
are convenient for
patients, in person or by
phone or
videoconferencing.
I am offered the
option to have an inperson visit, speak
with a behavioral
health care provider
during my primary
care visit, or have a
follow-up phone call
from a member of
the integrated care
team. I can elect to
receive services inperson, by phone, or
via other
mechanisms that
are most convenient
for me.
The integrated care team
has access to actionable
medical and behavioral
health information via a
shared care plan at the
point of care. Clinicians
work together via
regularly scheduled
consultation and
coordination to jointly
address the patient’s
shared care plan.
I have access to my
own care plan if I
want to see it. When
I call the clinic, they
always know who I
am and what my
needs are. My
health care team
communicates well,
has access to the
same information,
and it feels like they
are all on the “same
page” about my
health goals.
Adopted by the Bree Collaborative, March 22, 2017.
Usual Care: Behavioral health services are available using a referral-based
approach (internally or externally). Patients may not be able to see the
provider to which they are referred in a timely way.
Steps Toward Integration: Behavioral health services are not consistently
scheduled and are occasionally available on the same day and in the same
location, although this is not routine practice.
Integrated Care: Appointment scheduling is managed and monitored for
behavioral health providers in much the same way as it is managed for
primary care providers. As much as possible, scheduling for practice-based
behavioral health providers allows availability on the same day as patients’
medical visits in a coordinated way. Behavioral health providers are
scheduled in such a way so as to allow sufficient time to engage patients in
their treatment through frequent visits and phone contacts, especially in the
first month of treatment. Patients have opportunities to access care easily
and conveniently through face-to-face and virtual interactions with the care
team.
Usual Care: Behavioral or medical information is not readily or systematically
available at the point of care; providers must rely on an “as needed”
request. There may be separate treatment goals in the EHR and/or lack of
coordination and communication in the pursuit of a shared treatment plan.
Steps Toward Integration: Primary care and behavioral health providers
have access to the same information through EHR or shared clinical care
management systems, but there is limited coordination and/or little ability
to track patients’ status over time.
Integrated Care: The integrated care team has an information system that
supports population-based care, systematically shares patient information,
and tracks patient outcomes over time. Patient information is incorporated
into a shared care plan whereby critical medical, behavioral, and social
information is recorded and accessible. Shared information includes current
and past medications, progress and visit notes, and relevant diagnoses. The
Page 7 of 37
integrated care team can easily track patients and work toward shared
treatment goals that are documented in the patient record.
4
5
Practice
Access to
Psychiatric
Services
Operational
Systems and
Workflows to
Support
PopulationBased Care
Access to psychiatric
consultation services is
available in a systematic
manner to assist the care
team in developing a
treatment plan and
adjusting treatments for
patients who are not
improving as expected
under their current plan.
For patients with more
severe or complex
symptoms and
diagnoses, specialty
behavioral health
services are readily
available and are well
coordinated with primary
care.
My integrated care
team is able to
consult with
specialists to make
sure that my
treatment is going
to help me. If I need
higher levels of care,
I am able to see a
specialist directly as
needed.
A structured method is in
place for proactive
identification and
stratification of patients
for targeted conditions.
The practice uses
systematic clinical
protocols based on
screening results and
other patient data, like
emergency room use,
that help to characterize
I am asked about
behavioral health
concerns (e.g.,
depression, anxiety,
alcohol, substance
use) at my first visit
and at least
annually thereafter.
If my screening
results suggest that
I may have
behavioral health
Adopted by the Bree Collaborative, March 22, 2017.
Usual Care: There is no agreement or staffing in place for psychiatric
consultation, telemedicine, or direct clinical services. If there is an
agreement or staffing in place, the services available are scarce and may not
be organized in such a way so as to leverage services to meet the needs of as
many patients as possible.
Steps Toward Integration: Staff have inconsistent access to psychiatric
consultation services, not regularly or systematically. Patient referrals to
psychiatric care occur but may not always be incorporated into the patient’s
care plan and must be requested individually per patient.
Integrated Care: Access to psychiatric consultation services are available in a
systematic manner so as assist the primary care provider and team to
develop a treatment plan and adjust treatments for patients who are not
improving as expected. Psychiatric services may be received virtually (via
video conference or by phone) if this method is more efficient or there is
limited access to face-to-face consultation. For patients with more severe or
complex symptoms and diagnoses, specialty services are readily available
and are well coordinated with primary care. Any referral includes shared bidirectional communication.
Usual Care: Behavioral health needs are not assessed or are occasionally
assessed. There is no way to systematically track patients who do screen
positive or this is done by individual providers patient by patient.
Steps Toward Integration: Screening for behavioral health needs is
incorporated as a pilot for selected group(s) of patients. Follow-up is a
normal part of care but patients are not contacted if they miss appointments
or if they do not show improvement.
Integrated Care: Patients are proactively screened using validated tools on
regular intervals for target conditions such as alcohol use disorder,
substance use disorder, and select mental health conditions (e.g., Alcohol
Page 8 of 37
6
EvidenceBased
Treatments
patient risk and
complexity of needs.
Practices track patients
with target conditions to
make sure patient is
engaged and treated-totarget/remission and
have a proactive followup plan to assess
improvement and adapt
treatment accordingly.
Age language, culturally,
and religiouslyappropriate
measurement-based
interventions for physical
and behavioral health
interventions are
adapted to the specific
needs of the practice
setting. Integrated
practice teams use
behavioral health
symptom rating scales in
a systematic and
quantifiable way to
determine whether their
patients are improving.
The goal of treatment is
to provide strategies that
include the patient’s
goals of care and
appropriate selfmanagement support.
Adopted by the Bree Collaborative, March 22, 2017.
concerns or screen
positive I am
introduced to
someone on the
team that is trained
to help me. I receive
the type of
treatment that is
best suited to me.
Use Disorders Test (AUDIT), Drug Abuse Screening Test (DAST-10), the
Patient Health Questionnaire (PHQ-2 or PHQ-9), and Generalized Anxiety
Disorder (GAD-7), among others). The practice also has a plan for recording,
tracking, and following-up based on screening results. For patients who do
not improve or do not have a follow-up visit scheduled, the practice reaches
out in an attempt to engage them, change the treatment approach, or
connect them with appropriate services.
My provider asks me
about my symptoms
and treatment goals
and incorporates
them into my
individualized
treatment plan.
I can track my own
progress over time
in much the same
way that I keep
track of my blood
pressure. My health
care team helps me
understand my
choices about the
type of treatment I
elect to receive and
the reasons for the
type of treatment.
Usual Care: While measurement-based medical care is routine practice
throughout the practice, (e.g., blood pressure cuffs, A1c tests for diabetes),
use of behavioral health measurement tools, such as symptom rating scales,
to monitor patients’ symptoms and progress toward treatment goals are not
used.
Steps Toward Integration: Evidence-based guidelines including selfmanagement support are available within the practice, but are not
systematically integrated into care. Use of evidence-based best practice
depends on the provider and is highly variable, not emphasizing selfmanagement strategies, or not adhering to behavioral therapies that are
amenable to a brief, episodic format.
Integrated Care: The practice routinely delivers age-, language, culturally,
and religiously-appropriate, evidence-based behavioral and physical health
interventions that are adapted to the practice setting and are integrated
across disciplines including, but not limited to, health behavior change
strategies, brief behavioral interventions, and appropriate medication
management/medication assisted treatment. Integrated practice teams use
behavioral health symptom rating scales in a systematic and quantifiable
way to determine whether patients are improving using a symptom rating
scale (e.g., as in using a blood pressure cuff to track treatment outcomes in
hypertension).
Page 9 of 37
7
8
Patient
Involvement
in Care
Patient goals inform the
care plan. The practice
communicates effectively
with the patient about
their treatment options
and asks for patient input
and feedback into care
planning. Patient
activation and self-care is
supported and
promoted.
Data for
System-level data
Quality
regarding access to
Improvement behavioral care, the
patients’ experience, and
patient outcomes is
tracked. If system goals
are not met, quality
improvement efforts are
employed to achieve
patient access goals and
outcome standards.
Adopted by the Bree Collaborative, March 22, 2017.
I have an active
involvement in my
care planning and
am encouraged and
supported to be
involved in my own
wellness as much as
possible. My
providers have
talked to me about
what integrated
care means for me
and have asked me
what I think about
access and quality. I
am asked about my
social support and
other needs I may
have.
The practice asks for
my feedback about
my experience at
the clinic. We
frequently assess
and reassess my
health goals
together to see how
I am improving and
where I need
support or advice. It
feels like the
practice is getting
better at serving my
needs.
Usual Care: Patients may be minimally engaged or not engaged in their own
treatment care plan and not asked about their treatment goals or
preferences.
Steps to Integration: Patients are sometimes but not regularly involved in
care decisions.
Integrated Care: Patients and the care team are partners in creating care
plans that support patient needs and are informed by best practice. Patients
are actively involved in their own care and they are asked about potential
barriers to care. Shared-decision aids are used whenever possible. Patient’s
health literacy level is considered in assessment and care planning. Care
plans include both clinician and patient action plans as clinically appropriate
Usual Care: Patient health data points are paper-based and/or kept
independently by providers.
Steps Toward Integration: Practice has an EHR but information on patients
is not systematically tracked and/or the data is not used for improvement in
a meaningful way.
Integrated Care: Practice systematically tracks physical and behavioral
health screening results and outcomes for all patients receiving integrated
care services. Practice collects data on program adherence and staffing
needs for program evaluation. Practice systematically collects data for all
identified patients that is focused on data points such as depression
screening and follow up, patient clinical outcomes in behavioral health,
timely access to services, utilization patterns, risk stratification, patient
experience, or other meaningful measurements.
Page 10 of 37
Stakeholder Actions and Quality Improvement Strategies
Patients and Family Members
• Review Table 1: Roadmap to Integrated Care. You should be receiving care that addresses both
physical and behavioral health needs. Read through the patient perspective on the eight
elements.
• Talk to your primary care provider or other care team members about any concerns including
feeling low or depressed, feeling anxious, concerns about drinking or drug use, or any other
concerns about behavioral health.
• Ask to see your care plan if you would like.
• Talk to your providers about your concerns with accessing the type of care that you need.
• Track progress on treatment for behavioral health diagnosis in the same way that you would
track something like blood pressure.
• Ask your care team about the reasons or evidence for the types of treatments that you receive.
• Give your feedback about your experience at the practice.
Primary Care Practices and Systems (including Primary Care and Behavioral Health Care Providers)
Review Table 1: Roadmap to Integrated Care. The following list includes key action items from the
Roadmap.
•
•
•
•
•
•
•
•
•
•
•
Clearly define roles for integrated care team members, including primary care and behavioral
health clinicians and staff.
Structure typical practice activities to facilitate involvement by all members of the integrated
care team (e.g., team meetings, daily huddles, pre-visit planning, quality improvement
meetings).
Facilitate patient access to behavioral health and primary care services on the same day as much
as feasible.
At a minimum, ensure that for each patient with an identified behavioral health need, a plan is
developed on the same day that includes continuous patient engagement in ways that are
convenient for patients, in person or by phone or videoconferencing.
Ensure that the integrated care team has access to actionable medical and behavioral health
information via a shared care plan at the point of care.
Ensure that clinicians work together via regularly scheduled consultation and coordination to
jointly address the patient’s shared care plan.
Facilitate access to psychiatric consultation services in a systematic manner to assist the care
team in developing a treatment plan and adjusting treatments for patients who are not
improving as expected under their current plan.
Coordinate specialty behavioral health services for patients with more severe or complex
symptoms and diagnoses.
Proactively identify and stratify patients for targeted conditions.
Use systematic clinical protocols based on screening results and other patient data, like ER use,
that help to characterize patient risk and complexity of needs.
Track patients with target conditions to make sure patient is engaged and treated-totarget/remission and have a proactive follow-up plan to assess improvement and adapt
treatment accordingly.
Adopted by the Bree Collaborative, March 22, 2017.
Page 11 of 37
•
•
•
•
•
•
Use age-appropriate measurement-based interventions for physical and behavioral health
interventions that are adapted to the specific needs of the practice setting.
Use behavioral health symptom rating scales in a systematic and quantifiable way to determine
whether patients are improving.
Include appropriate self-management support in care.
Use patient goals to inform the care plan.
Communicate effectively with the patient about treatment options and include patient goals,
perspectives, and informed treatment decisions into treatment plans.
Track system-level data regarding access to behavioral care, the patients’ experience, and
patient outcomes. If system goals are not met, use quality improvement efforts to achieve
patient access goals and outcome standards.
Health Plans
Partially adapted from SAMHSA’s ACAP Fact Sheet Safety Net Health Plan Efforts to Integrate Physical
and Behavioral Health at Community Health Centers5
•
Reimburse for Medicare primary care providers participating in a collaborative care program or
receiving other integrated behavioral health services as outlined in CMS Federal Register Final
Rule for Docket Number CMS-1654-F (e.g., G0502, G0503, G0504).
•
Work with health care purchasers to identify and provide data on outcome measurements
relevant to their population to better ensure treatment efficacy and patient access (e.g., NCQA
behavioral health treatment within 14 days, NCAQ anti-depressant medication management).
•
Develop and maintain strong, respectful relationships with practices including sharing
information, decision making, costs, and savings as appropriate.
•
Work with the Accountable Communities of Health to measure quality and outcomes including
traditional clinical measures but also data beyond care delivery and claims: arrests/recidivism,
housing status, employment, if possible.
Employers
• When designing benefits, work to eliminate inadvertent barriers to behavioral health care
services and integrating care for employees including equalizing benefit structures for
behavioral health and physical health care.
• If an employee assistance program is offered, promote employee understanding of behavioral
health benefits.
• Include behavioral health-related components in employee wellness programs (e.g., stress and
anxiety reduction, interventions around alcohol consumption).
Washington State Health Care Authority
• Certify patient decision aids around treatment options for common behavioral health conditions
(e.g., depression, anxiety, alcohol use, substance abuse).
Adopted by the Bree Collaborative, March 22, 2017.
Page 12 of 37
Problem Statement
Mental illness and substance use disorders, together called behavioral health, are common, with an
estimated 46% of adults experiencing mental illness or a substance abuse disorder at some point in their
lifetime, 25% in a year. 6 Many of these diagnoses are the result of trauma. Depression is by far the most
well-researched behavioral health diagnosis, approximately 16-23% of Americans experience a major
depressive episode in their lifetimes, 7.6% in any two-week period. 7,8,9 Episodes of major depressive
disorder typically last 16 weeks, almost all being clinically significant.7 Somatic symptoms, including
fatigue and pain, are associated with depression and anxiety, leading to higher use of medical care. 10
Approximately 8.4% of Americans have a substance use disorder, 20.2 million adults; 7.9 million also
having a co-occurring mental disorder. 11
Patients with chronic medical conditions and behavioral health issues have an estimated two to three
times higher health care costs. 12 Depression is especially common among those with a chronic illness,
such as diabetes, resulting in lower adherence to clinical recommendations, worse physical functioning,
and higher cost. 13 Behavioral health disorders also lead to higher rates of early mortality, contributing to
approximately eight million deaths annually across the world (14.3%) and a median of 10 years of lost
life. 14
High Unmet Need
Measurement-based medical care is routine practice throughout primary care medical treatment such
as from blood pressure cuffs to A1c tests for diabetes. Yet few practices routinely administer simple
proven measurement tools, such as symptom rating scales, to monitor their patients’ symptoms and
progress toward behavioral health treatment goals. Best practice care management processes are used
less often for depression and other behavioral health diagnoses than for asthma, diabetes, or congestive
heart failure in primary care, showing a gap both in comprehensive assessment and evidence-based,
supportive treatment. 15
There are many barriers to behavioral health care access including far greater stigma attached to mental
health and substance abuse diagnoses than for other conditions. Additionally, behavioral health has a
less developed state and national infrastructure for measuring and improving care quality; the need for
connecting a greater variety and number of siloed clinicians, specialists, and organizations; lower use of
health information technology; and barriers in the health insurance marketplace. 16 Partially due to these
barriers and to a lack of education and training among clinicians, screening for and comprehensive
access to treatment for depression occur infrequently. 17 This is especially true in Washington State
which has been ranked 48th on measures of need for mental health services compared to access. 18
The Case for Integration
This high unmet need and siloed nature of behavioral health and physical health care were identified in
the 2006 Institute of Medicine Crossing the Quality Chasm series as contributing to low-quality care. 19
On average, 80 million Americans visit an ambulatory care center with major depressive disorder as
their primary diagnosis, indicating potential to impact patient outcomes through treatment within the
context of primary care. 20 Primary care providers have reported preferring integrated care, reporting
Adopted by the Bree Collaborative, March 22, 2017.
Page 13 of 37
more effective communication and lower stigma about mental health and substance use for patients. 21
Research has consistently shown healthier patients and populations including decreased depression,
anxiety, and positive impacts on medical conditions including diabetes, increases in quality of life, and
higher patient satisfaction. 22,23 It is clear that screening without adequate treatment, referral to
specialty care without close coordination or follow-up, and co-located behavioral health specialists
without systematic tracking of outcomes or evidence-based treatments do not work and are not
recommended.
Addressing behavioral health needs within primary care for the majority of patients is cost-saving. The
Institute for Clinical and Economic Review estimates that behavioral health integration using the
Collaborative Care Model represents a valuable improvement. 24 Primary care settings are the natural
home for behavioral health services for the majority of the population, enhancing access to behavioral
health care, reducing stigma, and increasing physical and behavioral health in a cost-effective manner. 25
Additionally, those with severe and persistent mental illness often lack access to primary care and may
be more comfortable receiving services within a behavioral health practice. Integrating behavioral
health into primary care, and providing physical health care services within the walls of behavioral
health practices, has been clearly called out as a means to achieve whole-person, patient-centered care.
Adopted by the Bree Collaborative, March 22, 2017.
Page 14 of 37
Background: Towards an Integrated System
This section is offered as a discussion in support of the eight elements framework and is not a complete
list of all research that has been completed about primary care, behavioral health care, or integration
nor a specific endorsement of any of the models, frameworks, or studies discussed below.
Integrating behavioral and physical health or primary care, or integrated care, is an evolving field.
Traditionally, patients receive the majority of their medical or physical care within the context of
primary care with both mental health services and substance use disorder treatment as specialty
services typically located in separate facilities and reimbursed through separate mechanisms.
The Institute of Medicine adapted their 2001 strategy for overall health care improvement to mental
and substance use conditions with the goals that: 26
•
“Individual patient preferences, needs, and values prevail in the face of residual stigma,
discrimination, and coercion into treatment.
•
The necessary infrastructure exists to produce scientific evidence more quickly and promote its
application in patient care.
•
Multiple providers' care of the same patient is coordinated.
•
Emerging information technology related to health care benefits people with mental or
substance-use problems and illnesses.
•
The health care workforce has the education, training, and capacity to deliver high-quality care
for mental and substance-use conditions.
•
Government programs, employers, and other group purchasers of health care for mental and
substance-use conditions use their dollars in ways that support the delivery of high-quality care.
•
Research funds are used to support studies that have direct clinical and policy relevance and that
are focused on discovering and testing therapeutic advances.”
Many integrated models are conceptually based on the Chronic Care Model developed by Wagner and
colleagues in 2001; an integrated system of interventions focused on patients with chronic illness (e.g.,
diabetes, asthma) moving along a continuum from minimal integration to fully integrated care.27,28
Wagner’s Chronic Care Framework includes delivery system redesign linked to community resources,
patient self-management support and education, evidence-based decision support integrated into the
practice, and standardized patient data collection including disease registries (e.g., clinical information
systems).
Other influential models were developed to target patient needs for behavioral health or physical health
care services based on specific care setting. Barbara Mauer developed four quadrants to describe clinical
integration based on identified patient need for either physical health intervention or behavioral health
intervention, see Figure 2 on the following page. 29 In Mauer’s model, primary care serves patients with
low or high physical health and low behavioral health needs, while specialty mental health is meant to
serve those with higher behavioral health needs.
Adopted by the Bree Collaborative, March 22, 2017.
Page 15 of 37
Figure 2: Four Quadrant Model for Behavioral Health Integration28
Low ----------------Physical Health Complexity--------------------High
High
Behavioral Health Complexity
Low
II: High behavioral health need
Low physical health need
IV: High behavioral health need
High physical health need
Setting: Specialty Mental Health
and Primary Care
Example: Schizophrenia
Setting: Specialty Mental Health
and Primary Care
Example: Schizophrenia and
uncontrolled diabetes
I: Low behavioral health need
Low physical health need
III: Low behavioral health need
High physical health need
Setting: Primary Care
Example: Moderate alcohol use
Setting: Primary Care
Example: Uncontrolled diabetes
Integrating Behavioral Health into Physical Health
Since the initial work to develop conceptual models for integrated care detailed earlier, research into
the effect of specific components on patient outcomes, most notably on depression remission, has
grown rapidly. The Agency for Healthcare Research and Quality (AHRQ) and others including the
Millbank Memorial fund have regularly conducted systematic literature reviews, from which this Report
and Recommendations heavily draws. AHRQ first published their report Integration of Mental
Health/Substance Abuse and Primary Care in 2008 to describe the current state of integration in various
practice settings, barriers to that integration, and other factors affecting feasibility of the models such as
health information technology and reimbursement structures. 30 The review found 33 trials, 26 of which
addressed depression, and the majority of which used the Wagner Chronic Care Model described but
that differed greatly in level of provider integration and in specific processes. While the individual
studies tended to demonstrate positive patient outcomes (e.g., depression or anxiety remission),
researchers did not find an association between level of integration (e.g., presence of care processes
including screening, coordinated care, clinical monitoring, medication adherence among others) and
greater improvement in outcomes.25
Medical homes, while not specifically focused on integrated behavioral health, meet many of the
requirements of supporting a patient’s behavioral and physical health needs. The National Committee
for Quality Assurance (NCQA) has defined criteria for medical homes (also called patient-centered
medical homes) that include tracking patients with a registry, case management using allied health
professionals, adherence to evidence-based guidelines, self-management support, universal screening,
and supported referrals to specialty care. 31 Health homes, defined by the 2010 Affordable Care Act, are
centered on patients with mental health and substance use disorders and other chronic conditions. 32
See Figure 3: Current Models of Behavioral Health System Integration Continuum on the following page
for an outline of these care settings.
Adopted by the Bree Collaborative, March 22, 2017.
Page 16 of 37
The Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington has
developed the evidence-based Collaborative Care Model (CCM), “a specific type of integrated care…that
treats common mental health conditions such as depression and anxiety that require systematic followup due to their persistent nature…[focused] on defined patient populations tracked in a registry,
measurement-based practice and treatment to target. Trained primary care providers and embedded
behavioral health professionals provide evidence-based medication or psychosocial treatments,
supported by regular psychiatric case consultation and treatment adjustment for patients who are not
improving as expected.” 33 A systematic literature review of Collaborative Care for patients with anxiety
or depression found 79 randomized controlled trials showing significantly greater improvement in
depression and anxiety symptoms in the short and long-term and benefits for patient satisfaction. 34
Patients with depression choosing Collaborative Care over usual care had a shorter median time to
remission of depression, 86 days compared to 614 days. 35
Primary care behavioral health (PCBH) is a promising practice with emerging evidence that is a
population-based approach to mental health care simultaneously co-located, collaborative, and
integrated within a primary care clinic. Behavioral health consultants (BHCs) work side by side with
members of the clinical care team, including primary care providers, nursing/medical staff, dietitians,
and others, to provide behavioral assessment and focused intervention at the point of care. An essential
component of the PCBH model is the use of “warm hand-offs” whereby patients are immediately
referred by care team members and met by BHCs in the context of their original medical visit. These
“warm hand-offs” allow for real-time communication between medical and behavioral personnel to
facilitate a collaborative, whole-person care plan for patients and increase patient access to behavioral
care by removing common barriers to patients seeking mental health services (e.g., stigma, shame,
transportation limitations, childcare issues). Typical visits by BHCs are brief (lasting 10-30 minutes),
solution-focused, and aim to provide patients tangible behavioral skills to improve daily functional
abilities. BHCs are flexible members of the care and possess a generalist, well-rounded skillset to match
the wide array of patient needs that enter a practice (e.g., depression, anxiety, substance abuse, sleep
hygiene, smoking cessation, marital discord, grief, parenting, situational stress). Emerging research
supports PCBH in treatment for depression, post-traumatic stress disorder, generalized anxiety disorder,
adult general mental health functioning, pediatric diagnoses, and in reducing stigma.3544 36,3738,3940,414243,44,45
Many Washington State providers combine elements of both, or more, of these models into their
successfully integrated practices.
Millbank Memorial fund has published two comprehensive literature reviews, Evolving Models of
Behavioral Health Integration in Primary Care in 2010 and an update Evolving Models of Behavioral
Health Integration: Evidence Update 2010-2015 in 2016. The 2010 review identified eight models in use
across the United States: improved collaboration, medically provided behavioral health care, colocation, disease management, reverse co-location, unified primary care and behavioral health, primary
care behavioral health, and collaborative system of care. 46 Millbank categorized these eight models
based on shared elements as coordinated, collocated, or integrated. Millbank’s 2016 evidence update
Adopted by the Bree Collaborative, March 22, 2017.
Page 17 of 37
found a marked increase in the number of studies of integrated health, an expanded focus on diagnoses
outside of depression, the majority focused on enhanced collaboration and coordination of care (88%)
and a much smaller number (12%) focused on collocated care. 47 Many of the studies found integration
of care managers providing systematic follow-up, communication with providers, and some
psychological intervention. However, research has been limited in focusing on specific populations and
diseases, rather than the multiple chronic conditions affecting real patients and across multiple practice
settings.
The reviews helped inform the Substance Abuse and Mental Health Services Administration’s 2013
continuum of models that are detailed below: 48
•
Coordinated
o Level 1: Minimal Collaboration – Separate facilities and systems, little to no
communication
o Level 2: Basic Collaboration at a Distance – Separate facilities and systems,
communication based on specific issues or patients
•
Co-Located
o Level 3: Basic Collaboration Onsite – Behavioral and physical health providers located at
the same site, separate systems, referral process to behavioral health
o Level 4: Close Collaboration with Some System Integration – Providers located at same
site, some shared systems and records, some face-to-face communication
•
Integrated
o Level 5: Close Collaboration Approaching an Integrated Practice – Providers work as a
team, frequent communication, may have separate medical records
o Level 6: Full Collaboration in a Transformed/Merged Practice – Providers work as a
team, patients have a single treatment plan, all patients are treated as a whole person
Adopted by the Bree Collaborative, March 22, 2017.
Page 18 of 37
Figure 3: Current Models of Behavioral Health System Integration Continuum
Screening, Brief Intervention, and Referral to Treatment
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based paradigm seeking
to encourage health care providers to systematically “identify, reduce, and prevent problematic use,
abuse, and dependence on alcohol and illicit drugs.” 49 The Bree Collaborative developed
recommendations around integrating the SBIRT model into primary care, prenatal, and emergency room
settings in January 2014. Our current Behavioral Health Integration Report builds on and expands upon
this previous Report. The previous Report outlines the impact of drug and alcohol misuse in Washington
State and proposes the SBIRT model to provide early motivational conversations with people prior to
alcohol and other drug misuse overly impacting their lives. SBIRT has been endorsed by SAMHSA,
supporting an SBIRT model that: 50
•
Is brief
•
Universally screens all patients for a specific issue (e.g., alcohol and other drug misuse)
•
Occurs in a non-chemical dependency treatment setting (e.g., primary care, hospital)
•
Includes a seamless transition between screening, brief intervention, brief treatment, and referral
to specialty chemical dependency treatment
•
Demonstrates success
This preventative approach to screening has been endorsed by the United States Preventive Services
Task Force (USPSTF) that have recommended “clinicians screen adults aged 18 years or older for alcohol
misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling
interventions to reduce alcohol misuse” giving the recommendation a B rating meaning that, “there is
high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is
moderate to substantial.” 51 However, the USPSTF does not recommend screening for alcohol and drug
Adopted by the Bree Collaborative, March 22, 2017.
Page 19 of 37
use or for depression if there is no pathway to treat the patient within the practice or refer a patient to
appropriate treatment. Screening alone is not recommended.
Our model of integrated behavioral health builds on the proven SBIRT model and expands the protocol
to beyond that of screening for alcohol and other drug misuse and offering brief intervention or referral
to treatment as needed.
Integrating Primary Care into Behavioral Health
While the potential for improved patient outcomes and increased access to care is greater for those
with more severe mental illness and substance abuse, research into outcomes of integrating primary
care services into behavioral health settings is more limited. Focusing on both types of integration is
often called bi-directional integration and is a focus within Washington State, but beyond the scope of
this Report. The 2008 AHRQ review found three trials of this type of integration, all of which used the
Collaborative Care Model.29 All found increased positive patient health outcomes and two were costneutral due to declines in hospital and emergency room use.
Millbank Memorial Fund expanded their focus on integrated care with a 2016 update Integrating
Primary Care into Behavioral Health Settings: What Works for Individuals with Serious Mental Illness and
found 12 randomized controlled trials for patients with bipolar disorder, other serious mental illness,
and chemical dependency. 52 Most of the studies took place in large integrated health systems (e.g.,
Kaiser Permanente, Group Health Cooperative) and used care management to facilitate care
coordination around the patient and patient education on self-management. All the interventions met
the four components of the Wagner Chronic Care Model (delivery system redesign, patient selfmanagement support, guideline- and specialist-based decision support, and supportive clinical
information systems).26 In four of the studies, a primary care provider was fully integrated into the
mental health or chemical dependency facility, with full access to shared medical records, and
participation in team meetings for joint care planning. The other studies either had onsite enhanced
collaboration with an initial evaluation followed by arrangements for primary care near the facility or
off-site primary care with care managers facilitating collaboration. Results from the systematic review
grouped by patient population are:51
•
Four of the studies were focused on patients with bipolar disorder (in mental health practices or
at Group Health Cooperative), in general finding a decrease in length of mania episodes and
symptoms, increased mental health-related quality of life, better access to care but lower
quality evidence for better blood pressure control and better physical health-related quality of
life compared to usual care.
•
Three studies focused on patients with other serious mental illness (in mental health practices
or an acute inpatient psychiatric ward) finding greater use of preventative services,
improvements in mental health-related quality of life, and variable improvement in healthrelated quality of life, lower emergency department use, and variable costs compared to usual
care.
Adopted by the Bree Collaborative, March 22, 2017.
Page 20 of 37
•
Five of the studies were focused on patients with a substance use disorder (in a residential
detoxification unit, Veterans Administration, Kaiser Permanente chemical dependency
treatment, or hospital-based methadone maintenance clinic) and found that on-site medical
care with team meetings and joint treatment planning may improve abstinence rates with
uncertain impact on health care utilization and cost compared to usual care. Interestingly, the
studies indicate that collocated primary care alone, without actual integration or enhanced
collaboration, may not improve abstinence rates or health-related quality of life.
•
Long-term outcomes are unknown due to short follow-up periods as well as well as robust data
on cost or the effect of integrated care on patients with co-occurring mental health and
substance use disorders.
Adopted by the Bree Collaborative, March 22, 2017.
Page 21 of 37
Deeper Dive: The Patient Perspective
We include this section here to compliment and re-iterate our inclusion of the eight element from the
patient perspective and to emphasize the importance of basing care plans on patient goals.
Primary Care Practice
I don’t like going to doctors, and I’ve never really thought about talking about how I feel with my doctor. This
time when I went to the practice I got a sheet of paper with the usual questions on it, like, how would I
describe my health, if I eat vegetables, I expected those questions. But this one asked me if I have had any
major changes in my life, good or bad. Well, I lost my job of 15 years about four months ago and although I’ve
been doing a little work on the side, losing my job is rough all the way around. One question asked whether I
have any interest in doing things, and whether I’ve been feeling down the last couple weeks. So I wrote I
haven’t been feeling like myself lately, which is an understatement. I also decided I would write that maybe
I’ve been drinking a little too much lately.
When I went in to see my doctor she looked at my answers and asked me a couple more about how I was
doing. She asked questions like it was part of what was going on with me and my health, how losing my job
has really made me feel down and maybe that was impacting me more than I realized. She was so
understanding, it was a relief for me to be able to talk about what was going on. She also said my blood
pressure was up, and it might have something to do with how I was feeling, and the excess drinking I’ve been
doing, plus not getting out and moving like I used to do in my work. So besides trying some blood pressure
medication and encouraging me to exercise, my doctor asked me if I would be ok if she brought in a clinician
who might be helpful to talk through my situation some more, to find some ways that might support me while
I am dealing with all this. Five minutes later I’m talking to this other clinician about how I’ve been feeling and
what might be helpful, so I can set some new goals for myself and make my life work better for me. I don’t
know how soon I am going to get a new job, but I do know it’s going to be easier if I’m feeling good all
around.
Behavioral Health Clinic
I don’t always feel like I belong in Primary Care when I go to a Doctor’s office and sometimes I think they don’t
even want me there. Plus I don’t always trust doctors I don’t know. So I just never went. But my Care
Coordinator at the Mental Health Clinic really thought I should see a Doctor, and she helped me set up an
appointment. She said she would go with me if I wanted her too, and that made me feel better about going.
I was nervous at first to see the Doctor because I hadn’t had a check-up in forever, but it was right there at the
Mental Health Clinic so I figured it might be ok. Everyone at the Clinic made me feel comfortable and I got
through the check-up OK. The Doctor saw the spot on my face that has been bothering me, and he said he
wanted to check it out and make sure it wasn’t cancer. It was, but it was still easy to take off and that made
me glad I went.
You know, I didn’t know that people cared about my physical health, I thought they just cared about my
mental health. Well, that, and whether I am drinking again. So I feel really good about that. When I was
there, my Doctor took my blood too, to find out if everything is fine. I think my prescriptions make me
overweight, and I don’t get out much, so he wants to make sure I don’t have diabetes or anything else. He
seemed kind and respectful, and he treated me well, so I’ll go back again when I need to. In fact, he said if
something happened on the weekend, that I could call a number and if he couldn’t help, another Doctor could,
so I don’t have to go to the Emergency Room now that I know that.
Adopted by the Bree Collaborative, March 22, 2017.
Page 22 of 37
Measurement
Measurement is a key component of our eight element framework described earlier. We include the
following section to outline national and state-level measures and processes, acknowledging that the
more holistic approach to behavioral health care is not necessarily reflected in the measures described
below that are mostly focused on depression. This emphasis on depression metrics is reflective of the
lack of well-developed alternatives rather than an emphasis on depression as a diagnosis. We encourage
use of the Washington State Common Measure Set on Health Care Quality and Cost.
Healthcare Effectiveness Data and Information Set
The Centers for Medicare and Medicaid Services adopted behavioral health measures for Accountable
Care Organizations in 2016 focused on depression readmission or response at 12 months. 53 The National
Committee for Quality Assurance recently developed Healthcare Effectiveness Data and Information Set
(HEDIS) measures for 2017 that include expectation of depression remission and/or response within five
to seven months. Studies have supported this shorter time to readmission using evidence-based
collaborative care interventions. The Collaborative supports an expectation of depression remission
and/or response within five to seven months.
HEDIS 2017 includes two depression-specific measures:
•
Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
•
Depression Remission or Response for Adolescents and Adults
The HEDIS measure, Depression Remission or Response for Adolescents and Adults, allows health
plans to assess and report the percentage of health plan members 12 years and older with a
diagnosis of depression who had evidence of response or remission within 5 to 7 months of
their initial diagnosis. Remission is documented by a PHQ-9 score less than 5 points and
response is indicated by a 50% decrease over the initial PHQ-9 score. This is one of only two
measures for which health plans have the option of using an Electronic Clinical Data System
(ECDS) such as a registry or other clinical management tracking system in addition to their EHR
to capture reporting data. More information can be found here: www.ncqa.org/hedis-qualitymeasurement/hedis-measures/hedis-2017
National Quality Forum
National Quality Forum measure 0418 (NQF 0418) Screening for clinical depression and follow-up plan
“Percentage of patients aged 12 years and older screened for clinical depression on the date of the
encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up
plan is documented on the date of the positive screen.” This measure is consistent with the need to
impact and measure the impact of access to mental health treatment in Washington State. More
information can be found here: www.aana.com/resources2/qualityreimbursement/Documents/2016_PQRS_Measure_134_11_17_2015.pdf
Adopted by the Bree Collaborative, March 22, 2017.
Page 23 of 37
Washington State Common Measure Set on Health Care Quality and Cost
The Healthier Washington Common Measure Set on Health Care Quality and Cost was mandated
through ESHB 2572 to set a foundation for measuring performance state-wide. The most recent
iteration, approved for 2017, includes six behavioral health-focused measures including:
•
Adult Mental Health Status. Measured by the Department of Health through Washington State
the Behavioral Risk Factor Surveillance System survey.
o The percentage of adults ages 18 and older who answer “14 or more days” in response
to the question, “Now thinking about your mental health, which includes stress,
depression and problems with emotions, for how many days during the past 30 days
was your mental health not good?” on the Behavioral Risk Factor Surveillance System.
•
Mental Health Service Penetration (Broad Version). Measured by health plans and Washington
State Department of Social and Health Services (DSHS) from claims data.
o The percentage of members with a mental health service need who received mental
health services in the measurement year. Separate reporting for age groups: 6-17 years
and 18-64 years.
•
Substance Use Disorder Service Penetration. Measured by DSHS from claims data.
o The percentage of members with a substance use disorder treatment need who
received a substance use disorder treatment in the measurement year. Reported for
Medicaid only. Separate reporting for age groups: 6-17 years and 18-64 years.
o This measure is reported for Medicaid only.
•
Antidepressant Medication Management. Measured by the Washington Health Alliance from
Claims data.
o The percentage of members 18 years and older who were treated with antidepressant
medication, had a diagnosis of major depression and who remained on an
antidepressant medication treatment.
o Two rates will be reported: Effective Acute Phase Treatment and Effective Continuation
Phase Treatment.
•
Follow-up After Hospitalization for Mental Illness. Measured by health plans from claims data.
o The percentage of discharges for members 6 years of age and older who were
hospitalized for treatment of selected mental illness diagnoses and who had a follow-up
visit with a mental health practitioner within 30 days of discharge.
•
30-day Psychiatric Inpatient Readmissions. Measured by DSHS from claims data.
o For members 18 years of age and older, the number of acute inpatient psychiatric stays
that were followed by an acute readmission for a psychiatric diagnosis within 30 days.
o This measure is reported for Medicaid only.
Learn more about the Common Measure Set: www.hca.wa.gov/about-hca/healthier-washington/performancemeasures and www.hca.wa.gov/sites/default/files/measures_fact%2520sheet.pdf
Adopted by the Bree Collaborative, March 22, 2017.
Page 24 of 37
Current State of Integration
Clinical and financial integration are separate components of full integration. This Report and
Recommendations are focused on clinical integration, but clinical integration must be supported by
financial integration to be sustainable. Both federally and at a state-level, the health care community is
moving toward both integrated care and integrated financing. The Centers for Medicare and Medicaid
Services announced in November 2016 a final rule revising payment for Medicare for primary care
services for patients with multiple chronic conditions including behavioral health issues participating in
an integrated care structure including Collaborative Care. 54 These codes allow the primary care provider
to bill for “behavioral health care manager activities, in consultation with a psychiatric consultant,” and
subsequent behavioral health care manager activities in increments of 60 and 30 minutes. 55 Find more
information via the AIMS Center here.
The Washington State health care community has shown a continued commitment to providing
evidence-based treatment to improve both physical and behavioral health across the State. Healthier
Washington, the Health Care Authority-managed program to transform the health care system through
encouraging value-based purchasing, community-directed health, and bi-directional behavioral and
physical health integration, is facilitating further transformation
Integrated Funding in Washington State
The Washington Medicaid Integration Partnership, a voluntary managed care pilot was initiated in
January 2005 in Snohomish County. 56 The pilot was administered by Molina Healthcare of Washington
for disabled Medicaid clients 21 years or older by funding medical care, substance use treatment,
mental health treatment, and long-term care services together. While the pilot did not demonstrate cost
savings, clients enrolled in the program did show lower mortality rates and inpatient hospital
admissions.
Senate Bill 6312, passed in 2014, directed the Department of Social and Health Services to “integrate
funding and oversight for behavioral health (mental health and substance use) treatment services…to
better coordinate care for people with co-occurring disorders.” 57 This change moved state-purchased
behavioral health from Regional Support Networks and counties to “Behavioral Health Organizations
(BHOs) to purchase and administer public mental health and substance use disorder services under
managed care” mainly for those with severe mental illness. 58 More information BHOs can be found here
and information on patient benefits can be found here.
By changing the reimbursement structure for mental health and substance use disorder services in the
state Medicaid (Apple Health) program, physical and behavioral health needs “will be addressed in one
system through an integrated network of providers, offering better coordinated care for patients and
more seamless access to the services they need.” 59 The Health Care Authority piloted this integration
starting April 1, 2016 in southwest Washington, Clark and Skamania counties, with Medicaid Managed
Care Organizations Molina Healthcare of Washington or Community Health Plan of Washington
Adopted by the Bree Collaborative, March 22, 2017.
Page 25 of 37
managing all three types of previously siloed care. A report on the first 90 days of the program is
available here and found: 60
•
Better care coordination
•
Reduced behavioral health administrative burdens
•
Lower emergency department visits
•
Necessary back-office changes so that behavioral health providers can bill the managed care
organizations rather than the previously existing regional support networks
Washington Screening, Brief Intervention, and Referral to Treatment
As discussed earlier, the SBIRT model is a platform from which to develop truly integrated behavioral
health, but alone is not sufficient to address mental health needs, substance use disorders, and physical
health. The Washington Screening, Brief Intervention, and Referral to Treatment Primary Care
Integration (WASBIRT) started as a five-year grant from SAMHSA from 2003 to 2008 to implement
Screening, Brief Intervention, and Referral to Treatment in nine emergency departments across the
state and a second grant on Primary Care Integration (WASBIRT-PCI) to expand to practices from 2011 to
2016.61 To date, 85,124 people have been screened in primary care practices in Cowlitz, Clallam, King,
Thurston, and Whitman Counties.
Sustainability past 2016 is a primary goal of the program and the Health Care Authority has opened
billing codes to reimburse for the brief intervention portion of SBIRT. In order to receive reimbursement
for SBIRT under Medicaid, the Health Care Authority requires those billing to have at least four hours of
training. Advanced registered nurse practitioners, mental health counselors, marriage and family
therapists, independent and advanced social workers, physicians, psychologists, dentists, and dental
hygienists can bill for SBIRT services and chemical dependency professionals, licensed practical nurses,
physician assistants, and registered nurses can provide the services but cannot themselves bill. Protocol
for the WASBIRT program includes:
1. Prescreen: Single-item alcohol and drug use asked to new patients, annually to all patients, and
at triage in the emergency department
2. Full Screen: If patient screens positive for alcohol or drug use, patient is given a full AUDIT or
DAST-10, as appropriate through written self-report or verbally asked by medical assistant or
nurse
3. Mental Health Screen: If patient screens positive for alcohol or drug use on the AUDIT or DAST10, they are also screened for depression with PHQ-9 and anxiety with GAD-7
•
•
•
Information about billing here.
Information about brief interventions here.
Information about training here.
Adopted by the Bree Collaborative, March 22, 2017.
Page 26 of 37
Mental Health Integration Program
The AIMS Center is leading a state-wide effort to integrate mental health screening and treatment into
safety net settings using the principles of Collaborative Care called the Mental Health Integration
Program (MHIP). Approximately 200 community health and mental health centers in Washington State
have enrolled, funded by the State Legislature, Public Health – Seattle and King County, and the
Community Health Plan of Washington so that 50,000 patients have received integrated care since
January 2008. 62
The PCBH model has expanded considerably over the last few years given its alignment with the patient
centered medical home’s whole-person orientation. One of major advantages of the PCBH model is it its
ability to reach a large segment of the population. On average, one full time BHC provides services to
1300-1700 unique patients annually depending on the setting and practice volume.38 With only 10 fulltime behavioral health providers, the Yakima Valley Farm Workers Clinic was able to provide services to
more than 13,000 patients in 2016. Many health centers in Washington State have also adopted the
PCBH model to help provide increased access to behavioral care to vulnerable populations.
Integrating funding of behavioral and physical health is a necessary first step to a whole-person system,
but not sufficient alone for true integration. Our goal is that our recommendations and specifically our
eight elements will be used to build on these models and existing infrastructure to increase access to
behavioral health services through primary care throughout Washington. Our goal is that providers and
practices have a clear pathway to integrated care and for people to know that Washington State has a
no-wrong-door philosophy to accessing care.
Adopted by the Bree Collaborative, March 22, 2017.
Page 27 of 37
Next Steps to Full Integration
Overcoming Barriers
Much of the research into integrating behavioral health is centered on strategies for overcoming
barriers to integration. Supporting material to Qualis Health’s Implementation Guide, Common Barriers
and Strategies to Support Effective Health Care Teams for Integrated Behavioral Health, identifies the
methods of overcoming barriers based on principles of effective teams including: shared goals, clear
roles, mutual trust, effective communication, and measurable processes and outcomes. 63
While not a comprehensive list, steps to overcoming barriers to implementation include:
•
Knowing Where to Start: There are many assessments and checklists to determine where to
start. Our workgroup does not endorse any one assessment and recommends practices use one
to meet their own needs or those of a program in which they are enrolled.
o AHRQ has developed a 37-question integration checklist available here:
https://integrationacademy.ahrq.gov/sites/default/files/playbook/Self_Assessment_Ch
ecklist_1.6.16.pdf
o Maine Health Access Foundation 21-question Site Self-Assessment available here:
https://integrationacademy.ahrq.gov/sites/default/files/measures/8_MEHAF_SSA.pdf
o Qualis Health’s Safety Net Medical Home Initiative 36-question Patient-Centered
Medical Home Assessment available here:
www.improvingchroniccare.org/downloads/pcmha.pdf
o Healthier Washington Practice Transformation Support Hub Resource Portal available
here: www.waportal.org
•
Making the Case: Facilitating buy-in is a key first step to integration.63 AHRQ has developed a
comprehensive website complete with videos to advocate for integrating behavioral health
here: https://integrationacademy.ahrq.gov/resources/videos.
o SAMHSA has developed a comprehensive toolkit to determine the financial business
case for integrating behavioral health here: www.integration.samhsa.gov/integratedcare-models/The_Business_Case_for_Behavioral_Health_Care_Monograph.pdf with a
corresponding Excel tool available for download here:
http://integration.samhsa.gov/integrated-caremodels/Business_Case_for_Behavioral_Health_Pro_Forma_Model.xlsx
•
Staffing: Hiring the right staff is important regardless of whether care is physically collated but
can be difficult for many practices. For practices working to have collocated care, hiring
behavioral health clinicians who have the skills, experience, and are comfortable working in a
primary care setting, is necessary. 64 Pragmatic research has repeatedly found the importance of
training behavioral health and primary care staff together to deliver patient-centered care as a
team. Staffing, and especially scheduling ratios of behavioral health to primary care clinicians
may need to be consistently revisited due to the complexity of a practice as an adaptive system
and any local and national changes.41 Higher ratios of behavioral health staff and flexible
Adopted by the Bree Collaborative, March 22, 2017.
Page 28 of 37
schedules are associated with warm handoffs that better support a patient rather than referrals
that can result in patients being lost in the system. 65 AHRQ outlines necessary staff
competencies including therapeutic skills such as motivational interviewing but also skills
necessary for working within primary care such as consultation skills. 66
•
Addressing Health Information Technology: Electronic health records (EHRs) are a key
component in multiple of our eight elements, most notably accessing and sharing patient
information and collecting data. However, EHRs are notoriously challenging especially with:
documenting and tracking behavioral health information (e.g., due to lack of a relevant template
and inability to track longitudinal data), supporting team-based communication and care
coordination, and exchanging information with other EHRs. 67 Practices should assess their needs
and capabilities early-on in the integration process and develop necessary workarounds.
Implementation Guides
There are many high-quality integration implementation guides including:
•
Agency for Healthcare Research and Quality: Behavioral Health Implementation Guide
Facilitates Integration integrationacademy.ahrq.gov/resources/new-and-notables/behavioralhealth-implementation-guide-facilitates-integration
•
American Academy of Pediatrics: Mental Health Initiatives tools for primary care
www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/PrimaryCare-Tools.aspx
•
AIMS Center: Collaborative Care Implementation Guide aims.uw.edu/collaborativecare/implementation-guide
•
SAMHSA-HRSA: Center for Integrated Health Solutions developed a quick start guide to
behavioral health integration for safety-net primary care providers:
www.thinglink.com/channel/622854013355819009/slideshow
•
Qualis Health: Implementation Guide to Behavioral Health Integration builds off previous
framework to move a practice into a patient-centered medical home model and uses the AIMS
Center’s five principles of integrated care, detailed previously. Available here:
www.safetynetmedicalhome.org/sites/default/files/Implementation-Guide-Behavioral-HealthIntegration.pdf
Adopted by the Bree Collaborative, March 22, 2017.
Page 29 of 37
Appendix A: Bree Collaborative Members
Member
Susie Dade MS
John Espinola MD, MPH
Gary Franklin MD, MPH
Title
Deputy Director
Executive Vice President, Health
Care Services
Medical Director
Stuart Freed MD
Richard Goss MD
Chief Medical Officer
Medical Director
Christopher Kodama MD
President, MultiCare Connected
Care
Chief Medical Officer
Daniel Lessler MD, MHA
Paula Lozano MD, MPH
Wm. Richard Ludwig MD
Greg Marchand
Robert Mecklenburg MD
Kimberly Moore MD
Carl Olden MD
Mary Kay O’Neill MD,
MBA
John Robinson MD, SM
Terry Rogers MD (Vice
Chair)
Jeanne Rupert DO, PhD
Kerry Schaefer
Bruce Smith MD
Lani Spencer RN, MHA
Hugh Straley MD (Chair)
Carol Wagner RN, MBA
Shawn West MD
Associate Medical Director,
Research and Translation
Chief Medical Officer, Accountable
Care Organization
Director, Benefits & Policy and
Strategy
Medical Director, Center for Health
Care Solutions
Associate Chief Medical Officer
Family Physician
Organization
Washington Health Alliance
Premera Blue Cross
Washington State Department of
Labor and Industries
Confluence Health
Harborview Medical Center –
University of Washington
MultiCare Health System
Washington State Health Care
Authority
Group Health Cooperative
Providence Health and Services
The Boeing Company
Virginia Mason Medical Center
Partner
Franciscan Health System
Pacific Crest Family Medicine,
Yakima
Mercer
Chief Medical Officer
Chief Executive Officer
First Choice Health
Foundation for Health Care Quality
Medical Director, Community
Health Services
Strategic Planner for Employee
Health
Medical Director
Vice President, Health Care
Management Services
Retired
Public Health – Seattle and King
County
King County
Senior Vice President for Patient
Safety
Family Physician
Adopted by the Bree Collaborative, March 22, 2017.
Regence Blue Shield
Amerigroup
Medical Director, Group Health
Cooperative; President, Group
Health Physicians
The Washington State Hospital
Association
Edmonds Family Medicine
Page 30 of 37
Appendix B: Behavioral Health Integration Workgroup Charter and Roster
Problem Statement
Untreated behavioral health disorders, including substance abuse, are debilitating and costly.
Approximately 23% of Americans experience a major depressive episode in their lifetimes, however
screening and comprehensive access to treatment happen infrequently. 1,2 Untreated depression and
anxiety are associated with poor health outcomes, increased health care costs, and a shorter life. 3
Washington State has been ranked 48th on measures of need for mental health services compared to
access. 4 The integration of behavioral health and primary care has been shown to increase access to
behavioral health services through decreased reliance on specialty care and be more patient-centered,
cost-saving, and result in healthier patients and healthier populations. 5
Aim
To improve the integration of behavioral health services and primary care across the State of Washington
starting with screening and increased access to treatment for depression.
Purpose
To propose evidence-based recommendations to the full Bree Collaborative on:
• Screening for depression
• Defining integrated approaches focused on enhancing behavioral health access and outcomes
• Referring to treatment for depression
• Best practices for overcoming barriers to patient-centered behavioral health care (e.g.,
information technology, 42 CFR)
• Measuring improvements and access to behavioral health care
• Identifying additional areas for recommendations
Duties & Functions
The Behavioral Health Integration workgroup will:
• Research evidence-based guidelines and best practices (emerging and established).
• Consult relevant professional associations and other stakeholder organizations and subject
matter experts for feedback, as appropriate.
• Meet for approximately nine months, as needed.
• Provide updates at Bree Collaborative meetings.
• Post draft report on the Bree Collaborative website for public comment prior to sending report to
the Bree Collaborative for approval and adoption.
• Present findings and recommendations in a report.
• Recommend data-driven and practical implementation strategies.
• Create and oversee subsequent subgroups to help carry out the work, as needed.
• Revise this charter as necessary based on scope of work.
National Institutes of Mental Health. Major Depression Among Adults. Available: http://www.nimh.nih.gov/health/statistics/prevalence/major-depression-amongadults.shtml. Accessed: August 2015.
2Harrison DL, Miller MJ, Schmitt MR, Touchet BK. Variations in the probability of depression screening at community-based physician practice visits. Prim Care
Companion J Clin Psychiatry. 2010;12(5)
3 National Institute of Mental Health. What is Depression? Available: http://www.nimh.nih.gov/health/publications/depression/index.shtml. Accessed: August 2015.
4 Mental Health America. Parity or Disparity: The State of Mental Health in America 2015.
www.mentalhealthamerica.net/sites/default/files/Parity%20or%20Disparity%202015%20Report.pdf
5 AIMS Center. Dollars and Sense. 2014. Available: http://aims.uw.edu/collaborative-care/dollars-sense. Accessed: August 2015.
1
Adopted by the Bree Collaborative, March 22, 2017.
Page 31 of 37
Structure
The workgroup will consist of individuals appointed by the chair of the Bree Collaborative or the
workgroup chair and confirmed by Bree Collaborative members.
The chair of the workgroup will be appointed by the chair of the Bree Collaborative.
The Bree Collaborative project director will staff and provide management and support services for the
workgroup.
Less than the full workgroup may convene to: gather and discuss information; conduct research; analyze
relevant issues and facts; or draft recommendations for the deliberation of the full workgroup. A quorum
shall be a simple majority and shall be required to accept and approve recommendations to send to the
Bree Collaborative.
Meetings
The workgroup will hold meetings as necessary. The program director will conduct meetings along with
the chair, arrange for the recording of each meeting, and distribute meeting agendas and other materials
prior to each meeting. Additional workgroup members to be added at the discretion of the chair.
Member
Brad Berry
Regina Bonnevie, MD
Title
Executive Director
Medical Director
Michelle Guerra, MD
Larry Marx, MD
Senior Clinician
Medical Director, Behavioral
Health Support Services
Behavioral Health Expert
Rose Ness, MA, LMHC, CDP
Kim McDermott, MD
Mary Kay O’Neill MD, MBA
Joe Roszak
Anna Ratzliff, MD, PhD/
Anne Shields, MHA, RN
Lani Spencer, RN, MHA
Physician
Partner
CEO
Director of the UW Integrated
Care Training Program, Associate
Director for Education/Associate
Director
Lead Psychologist
Program Director of Integrated
Behavioral Services
Behavioral Health Manager,
Oregon and Washington Services
Vice President
Milena Stott, LICSW, CDP
Emily Transue, MD, MHA
Melet Whinston, MD
Chief Of Inpatient Services
Senior Medical Director
Medical Director
Jeff Reiter, PhD
Julie Rickard, PhD
Brian Sandoval, PsyD
Adopted by the Bree Collaborative, March 22, 2017.
Organization
Consumer Voices Are Born
Peninsula Community Health
Services
Premera
Group Health Cooperative
Sound Integration for Behavioral
Healthcare
NeighborCare
Mercer
Kitsap Mental Health Services
AIMS Center, University of
Washington
Swedish Medical Services
Confluence Health
Yakima Valley Farm Workers Clinic
Health Care Management
Services, Amerigroup –
Washington
Valley Cities Counseling
Coordinated Care
United Health Care
Page 32 of 37
Appendix C: Crosswalk of Eight Elements with MeHAF
Questions II-1. Organizational leadership for integrated care and II- 9. Funding sources/resources underlie all elements
1
2
3
Element
Integrated Care Team
Patient Access to Behavioral
Health as a Routine Part of
Care
Accessibility and Sharing of
Patient Information
Link to MeHAF Question
II-2. Patient care team for implementing integrated care
II-3. Providers’ engagement with integrated care (“buy-in”)
II-8. Physician, team and staff education and training for integrated care
I-1. Co-location of treatment for primary care and mental/behavioral health care
I-12. Accessibility and efficiency of behavioral health practitioners
I-3. Treatment plan(s) for primary care and behavioral/mental health care
II-4. Continuity of care between primary care and behavioral/mental health
4
Practice Access to Psychiatric
Services
II- 5. Coordination of referrals and specialists
5
Operational Systems and
Workflows to Support
Population-Based Care
6
Evidence-Based Treatments
7
Patient Involvement in Care
8
Data for Quality Improvement
I-2. Screening/Assessment of emotional/behavioral health needs (e.g., stress, depression,
anxiety, substance abuse)
I-7. Follow-up of assessments, tests, treatment, referrals and other services
I-11. Tracking of vulnerable patient groups that require additional monitoring and intervention
I-4. Patient care that is based on (or informed by) best practice evidence for BH/MH and primary
care
I-10. Patient care based on (or informed by) best practice for prescribing of psychotropic
medications
I-5. Patient/family involvement in care plan
I-6. Communication with patients about integrated care
II-7. Patient/family input to integration management
II-6. Data systems/patient records
Adopted by the Bree Collaborative, March 22, 2017.
Page 33 of 37
References
1
Cohen DJ, Balasubramanian BA, Davis M, Hall J, Gunn R, Stange KC, et al. Understanding Care Integration from
the Ground Up: Five Organizing Constructs that Shape Integrated Practices. J Am Board Fam Med. 2015 Sep-Oct;28
Suppl 1:S7-20.
2
Peek CJ. Agency for Healthcare Research and Quality. Lexicon for Behavioral Health and Primary Care Integration.
AHRQ Grant No. 1R13HS021053-01. AHRQ Publication No. AHRQ 13-IP001-EF. April 2013. Available:
https://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf
3
Advancing Integrated Mental Health Solutions. Principles of Collaborative Care. 2016. Accessed: November 2016.
Available: https://aims.uw.edu/collaborative-care/principles-collaborative-care
4
Oregon Health Authority. Patient-Centered Primary Care Home Program 2014 Recognition Criteria. October 4,
2013. Available:
www.oregon.gov/oha/OHPR/Documents/2014%20PCPCH%20Recognition%20Criteria%20TA%20Guide%20FINAL%
2010.4.13.pdf
5
Association for Community Affiliated Plans. ACAP Fact Sheet Safety Net Health Plan Efforts to Integrate Physical
and Behavioral Health at Community Health Centers. September 2014. Accessed: December 2016.
www.integration.samhsa.gov/integrated-care-models/Integrated_Health_Fact_Sheet_ACAP.pdf
6
Kessler RC, Wang PS. The descriptive epidemiology of commonly occurring mental disorders in the United States.
Annu Rev Public Health. 2008;29:115-29.
7
National Institute for Mental Health. Major Depression Among Adults. Accessed: August 2016. Available:
www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml.
8
Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS; National
Comorbidity Survey Replication. The epidemiology of major depressive disorder: results from the National
Comorbidity Survey Replication (NCS-R). JAMA. 2003 Jun 18;289(23):3095-105.
9
Centers for Disease Control and Prevention. National Center for Health Statistics. October 2016. Accessed:
November 2016. Available: http://www.cdc.gov/nchs/fastats/depression.htm.
10
Kroenke K. Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and
management. Int J Methods Psychiatr Res. 2003;12(1):34-43.
11
Substance Abuse and Mental Health Services Administration. Mental and Substance Use Disorders. Accessed:
October 2016. Available: www.samhsa.gov/disorders.
12
Melek S. Milliman. Bending the Medicaid healthcare cost curve through financially sustainable medicalbehavioral integration. July 2012. Available: www.milliman.com/uploadedFiles/insight/healthpublished/pdfs/bending-medicaid-cost-curve.pdf.
13
Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence,
function, and costs. Arch Intern Med. 2000 Nov 27;160(21):3278-85.
14
Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a
systematic review and meta-analysis. JAMA Psychiatry. 2015 Apr;72(4):334-41.
15
Bishop TF, Ramsay PP, Casalino LP, Bao Y, Pincus HA, Shortell SM. Care Management Processes Used Less Often
For Depression Than For Other Chronic Conditions In US Primary Care Practices. Health Aff (Millwood). 35, 2016
Mar 1, Vol. 3, pp. 394-400.
16
Disorders Institute of Medicine (US) Committee on Crossing the Quality Chasm: Adaptation to Mental Health and
Addiction. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington DC :
National Academies Press, 2006.
17
Harrison DL, Miller MJ, Schmitt MR, Touchet BK. Variations in the probability of depression screening at
community-based physician practice visits. Prim Care Companion J Clin Psychiatry. 12, 2010, Vol. 5.
18
Mental Health America. Parity or Disparity: The State of Mental Health in America 2015. Accessed: May 2016.
Available: www.mentalhealthamerica.net/sites/default/files/Parity%20or%20Disparity%202015%20Report.pdf
19
Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington DC:
National Academy Press, 2001.
20
National Center for Health Statistics. FastStats Homepage Depression. Centers for Disease Control and
Prevention. April 2016. Accessed: July 2016. Available: www.cdc.gov/nchs/fastats/depression.htm.
Adopted by the Bree Collaborative, March 22, 2017.
Page 34 of 37
21
Gallo JJ, Zubritsky C, Maxwell J, Nazar M, Bogner HR, Quijano LM, Syropoulos HJ, Cheal KL, Chen H, Sanchez H,
Dodson J, Levkoff SE; PRISM-E Investigators. Primary care clinicians evaluate integrated and referral models of
behavioral health care for older adults: results from a multisite effectiveness trial (PRISM-e). Ann Fam Med. 2004
Jul-Aug;2(4):305-9.
22
Butler M, Kane RL, McAlpin D, Kathol R, Fu SS, Hagedorn H, et al. Integration of Mental Health/Substance Abuse
and Primary Care No 173 (Prepared by Minnesota Evidence-based Practice Center, Minneapolis, Minnesota under
contract 290-02-0009). Agency for Healthcare Research and Quality Publication Number 09-E003. Rockville, MD:
Agency for Healthcare Research and Quality, October 2008. Available:
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/mhsapc-evidencereport.pdf.
23
Tice JA, Ollendorf DA, Reed SJ, Shore KK, Weissberg J, Pearson SD. Integrating Behavioral Health into Primary
Care: A Technology Assessment. Institute for Clinical And Economic Review. June 2, 2015. https://icerreview.org/wp-content/uploads/2016/01/BHI_Final_Report_0602151.pdf
24
Institute for Clinical and Economic Review. Enhancing Patient Outcomes and Health System Value through
Integration of Behavioral Health into Primary Care. Policy Brief, June 2015. Accessed: July 2016. Available:
http://icer-review.org/wp-content/uploads/2015/06/BHI_Policy_Brief_060215.pdf
25
Collins C, Hewson DL, Munger R, Wade T. Evolving models of behavioral health integration in primary care. May
2010. Available: http://www.milbank.org/wpcontent/files/documents/10430EvolvingCare/10430EvolvingCare.html
26
Institute of Medicine (US) Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive
Disorders. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington (DC):
National Academies Press (US); 2006. Available: www.ncbi.nlm.nih.gov/books/NBK19830/
27
Wagner E, Austin B, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving Chronic Illness Care: Translating
Evidence into Action. Health Affairs 20(6):64–78.. Available: http://dx.doi.org/doi:10.1377/hlthaff.20.6.64.
28
Wagner E. 1998. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective
Clinical Practice 1(August/September):2–4. Available:
www.acponline.org/clinical_information/journals_publications/ecp/augsep98/cdm.pdf.
29
Mauer B. 2006. Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence-Based
Practices. Rockville, MD: National Council for Community Behavioral Healthcare. Available at www.
thenationalcouncil.org/galleries/business-practice%20files/4%20Quadrant.pdf/.
30
Agency for Healthcare Research and Quality. Integration of Mental Health/Substance Abuse and Primary Care.
Accessed: August 2016. Available: www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-basedreports/mhsapc-evidence-report.pdf
31
National Center for Quality Assurance. Patient-Centered Medical Home (PCMH) Recognition. Accessed: August
2016. Available: www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh
32
SAMHSA-HRSA Center for Integrated Health Solutions. Health Homes and Medical Homes. Accessed: November
2016. Available: www.integration.samhsa.gov/integrated-care-models/health-homes
33
Advancing Integrated Mental Health Solutions. Collaborative Care. 2016. Accessed: November 2016. Available:
https://aims.uw.edu/collaborative-care
34
Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for
depression and anxiety problems. Cochrane Database Syst Rev. 2012 Oct 17;10:CD006525.
35
Garrison GM, Angstman KB, O'Connor SS, Williams MD, Lineberry TW. Time to Remission for Depression with
Collaborative Care Management (CCM) in Primary Care. J Am Board Fam Med. 2016 Jan-Feb;29(1):10-7.
36
McFeature B, Pierce TW. Primary Care Behavioral Health consultation reduces depression levels among mooddisordered patients. Journal of Health Disparities Research and Practice. 2011; 5(2), 36-44.
37
Serrano N, Monden K. The effect of behavioral health consultation on the care of depression by primary care
clinicians. WMJ. 2011 Jun;110(3):113-8.
38
Cigrang JA, Rauch SAM, Avila LL, Bryan CJ, Goodie JL, Hryshko-Mullen A et al. Treatment of active-duty military
with PTSD in primary care: early findings. Psychol Serv. 2011;8:104–13.
39
Sandoval B, Cutts J, Chao B, Wilson L, Hawley P, Beckmann S, et al. Primary care behavioral health in Eastern
Oregon: Successes, challenges, and lessons learned. Presented at Oregon Health System Innovation Conference.
2015. Salem, OR.
Adopted by the Bree Collaborative, March 22, 2017.
Page 35 of 37
40
Bryan CJ1, Corso ML, Corso KA, Morrow CE, Kanzler KE, Ray-Sannerud B. Severity of mental health impairment
and trajectories of improvement in an integrated primary care clinic. J Consult Clin Psychol. 2012 Jun;80(3):396403.
41
Ray-Sannerud BN, Dolan DC, Morrow CE, Corso KA, Kanzler KE, Corso ML, Bryan CJ. Longitudinal outcomes after
brief behavioral health intervention in an integrated primary care clinic. Fam Syst Health. 2012 Mar;30(1):60-71.
42
Lang AJ. Mental health treatment preferences of primary care patients. Journal of Behavioral Medicine. 2005;
28, 581–586.
43
Chen H, Coakley EH, Cheal K, Maxwell J, Costantino G, Krahn DD et al. Satisfaction with mental health services in
older primary care patients. Am J Geriatr Psychiatry. 2006 Apr;14(4):371-9.
44
Runyan CN, Fonseca VP, Meyer JG, Oordt MS, Talcott GW. A novel approach for mental health disease
management: the Air Force Medical Service's interdisciplinary model. Dis Manag. 2003 Fall;6(3):179-88.
45
Torrence ND, Mueller AE, Ilem AA, Renn BN, DeSantis B, Segal DL. Medical provider attitudes about behavioral
health consultants in integrated primary care: a preliminary study. Fam Syst Health. 2014 Dec;32(4):426-32.
46
Collins C, Hewson DL, Munger R, Wade T. Evolving models of behavioral health integration in primary care. May
2010. Available: http://www.milbank.org/wpcontent/files/documents/10430EvolvingCare/10430EvolvingCare.html
47
Gerrity M. Milbank Memorial Fund. Evolving Models of Behavioral Health Integration: Evidence Update 20102015. May 2016. ISBN 978-1-887748-73-5. Available: http://www.milbank.org/wpcontent/uploads/2016/05/Evolving-Models-of-BHI-Exec-Sum.pdf
48
Heath B, Wise Romero P, and Reynolds K. A Standard Framework for Levels of Integrated Healthcare.
Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013. Available:
www.integration.samhsa.gov/integrated-caremodels/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf
49
SBIRT: Screening, Brief Intervention, and Referral to Treatment. Substance Abuse and Mental Health Services
Administration. Department of Health and Human Services. Accessed: November 2014. Available:
www.integration.samhsa.gov/clinical-practice/SBIRT.
50
Substance Abuse and Mental Health Services Administration. White Paper: Screening, Brief Intervention and
Referral to Treatment (SBIRT) in Behavioral Healthcare. April 1, 2011. Accessed: November 2014. Available:
www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf
51
Moyer VA, Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to
reduce alcohol misuse: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013 Aug
6;159(3):210-8.
52
Gerrity M. Integrating Primary Care into Behavioral Health Settings: What Works for Individuals with Serious
Mental Illness. April 2016. Available: www.milbank.org/wp-content/uploads/2016/04/Integrating-Primary-CareReport.pdf
53
Centers for Medicare and Medicaid Services. Consensus Core Set: ACO and PCMH / Primary Care Measures.
March 2, 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient54
Centers for Medicare and Medicaid Services. Final Policy, Payment, and Quality Provisions in the Medicare
Physician Fee Schedule for Calendar Year (CY) 2017. November 2, 2016.
www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-02.html
55
AIMS Center. Cheat Sheet on CMS Final Rule for 2017 Medicare Payments for Integrated Behavioral Health
Services. Updated: January 4, 2017
https://aims.uw.edu/sites/default/files/CMS_FinalRule_2017_CheatSheet.pdf
56
Mancuso D, Shah MF, Felver B, Nordlund D. Washington Medicaid Integration Partnership: Medical Care,
Behavioral Health, Criminal Justice, and Mortality Outcomes for Disabled Clients Enrolled in Managed Care.
December 2010. RDA Report number 9.100. Available:
https://www.dshs.wa.gov/sites/default/files/SESA/rda/documents/research-9-100.pdf.
57
Washington State Department of Social and Health Services. Developing Behavioral Health Organizations: Better
Care Through Integrated Behavioral Health Organizations. Accessed: November 2016. Available:
www.dshs.wa.gov/bha/division-behavioral-health-and-recovery/developing-behavioral-health-organizations
58
Washington State Department of Social and Health Services. Behavioral Health Organizations Fact Sheet.
Updated August 2015. Accessed: September 2016. Available: www.hca.wa.gov/hw/Documents/bhofactsheet.pdf.
Adopted by the Bree Collaborative, March 22, 2017.
Page 36 of 37
59
Washington State Health Care Authority. Integrated physical and behavioral health care. 2016. Accessed:
November 2016. Available: www.hca.wa.gov/about-hca/healthier-washington/integrated-physical-and-behavioralhealth-care
60
Washington State Health Care Authority. Delivery of Whole-Person Care in Southwest Washington: Report on
the First 90 Days of Fully Integrated Managed Care. August 2016. Available:
http://www.hca.wa.gov/assets/program/early-adopter-report.pdf.
61
SBIRT in Washington. Washington Screening Brief Intervention and Referral to Treatment: Primary Care
Integration. 2013. Accessed: September 2014. Available: www.wasbirt.com/content/sbirt-washington.
62
Advancing Integrated Mental Health Solutions. Washington State’s Mental Health Integration Program. 2016.
Accessed: November 2016. Available: https://aims.uw.edu/washington-states-mental-health-integration-programmhip
63
Safety Net Medical Home Initiative. Ratzliff A. Organized, Evidence-Based Care Supplement: Behavioral Health
Integration. Phillips KE, Holt BS, eds. Seattle, WA: Qualis Health, MacColl Center for Health Care Innovation at the
Group Health Research Institute, and the University of Washington’s AIMS Center; 2014. Available:
www.safetynetmedicalhome.org/sites/default/files/Common-Barriers-Strategies-Support-Health-Care-Teams.pdf
64
Hall J, Cohen DJ, Davis M, Gunn R, Blount A, Pollack DA, et al. Preparing the Workforce for Behavioral Health and
Primary Care Integration. J Am Board Fam Med. 2015 Sep-Oct;28 Suppl 1:S41-51.
65
Davis MM, Balasubramanian BA, Cifuentes M, Hall J, Gunn R, Fernald D, et al. Clinician Staffing, Scheduling, and
Engagement Strategies Among Primary Care Practices Delivering Integrated Care. J Am Board Fam Med. 2015 SepOct;28 Suppl 1:S32-40.
66
Kinman CR, Gilchrist EC, Payne-Murphy JC, Miller BF. Provider- and practice-level competencies for
integrated behavioral health in primary care: a literature review. (Prepared by Westat under Contract No.
HHSA 290-2009-00023I). Rockville, MD: Agency for Healthcare Research and Quality. March 2015. Available:
www.ccooregon.org/media/uploads/AHRQ_AcadLitReview.pdf
67
Cifuentes M, Davis M, Fernald D, Gunn R, Dickinson P, Cohen DJ. Electronic Health Record Challenges,
Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care. J Am Board
Fam Med. 2015 Sep-Oct;28 Suppl 1:S63-72.
Adopted by the Bree Collaborative, March 22, 2017.
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